Automatic Checking/ Savings Approval Form Name * First Name Last Name Phone * (###) ### #### Email (Please include your email address if you would like a receipt each month) Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Package Price $ Authorization * I hereby authorize Affordable Comfort LLC to initiate automatic withdrawals, in the amount listed above from my account at the financial institution named below. This agreement will remain in effect until Affordable Comfort LLC receives a written notice of cancellation from me or my financial institution, or until I submit an Automatic Checking/Savings withdrawal cancellation form to the Accounting Department at Affordable Comfort. Name of Financial Institution * Routing Number * Account Number * Thank you!
